Drivers of COVID-19 policy stringency in 175 countries and territories: COVID-19 cases and deaths, gross domestic products per capita, and health expenditures

Abstract

Background Reported COVID-19 epidemiological data may influence the stringency of COVID-19 policies, but the potential effects are not understood. We aimed to understand the associations of new COVID-19 cases and deaths with policy stringency globally and regionally.

Methods We modeled the marginal effects of new COVID-19 cases and deaths on policy stringency (scored 0–100) in 175 countries and territories, adjusting for gross domestic product (GDP), per capita and health expenditure (% of GDP), and public expenditure on health. Time periods examined were March–August 2020, September 2020–February 2021, and March–August 2021.

Results Policy response to new cases and deaths was faster and more stringent early in the COVID-19 pandemic (March–August 2020) compared to subsequent periods. New deaths were more strongly associated with stringent policies than new cases. In an average week, 1 new death per 100,000 people was associated with a stringency increase of 2.1 units in March–August 2020, 1.3 units in September 2020–February 2021, and 0.7 units in March–August 2021. New deaths in Africa and the Western Pacific were associated with more stringency than in other regions. Higher health expenditure as a percent of GDP was associated with less stringent policies. Similarly, higher public expenditure on health by governments was mostly associated with less stringency across all three periods. GDP per capita did not have consistent patterns of associations with stringency.

Conclusions The stringency of COVID-19 policies was more strongly associated with new deaths than new cases. Our findings demonstrate the need for enhanced mortality surveillance to ensure policy alignment during health emergencies. Countries that invest less in health or have a lower public expenditure on health may be inclined to enact more stringent policies. This new empirical understanding of COVID-19 policy drivers can help public health officials anticipate and shape policy responses in future health emergencies.

Aasli Abdi Nur

Postdoctoral Research Fellow in Computational Demography

Aasli Abdi Nur, PhD, MPH, is a Postdoctoral Research Fellow in the Department of Sociology at the University of Oxford.